Root Cause Analysis Blog

From the posting:

“The primary function of this position is to ensure compliance of all safety affairs as regulated through the Mine Safety and Health Administration (MSHA), California Occupational Health and Safety Administration (CALOSHA) and Occupational Health and Safety Administration (OSHA).  The successful candidate will conduct employee (task) training and monitor occupational exposure limitations, monitor safety progress against goals, implement safety programs, ensure report compliance, conduct investigations of safety including root-cause analysis with a focus toward prevention, etc.  A large emphasis will be placed on the manager’s ability to spark reforms and safety awareness throughout the facility.  Mining, construction, chemical, paper or steel industry experience would be a huge plus.  Individual contributors with management skills or aspirations will be considered.”

For more information, see:

http://catgroupinc.com/?p=226

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A wrong site surgery is a 100% preventable event. The administrative controls are fairly simple to implement. Yet, we still have wrong site surgeries.

An article from the Central New York News details an wrong site surgery on a patient’s hip. It seems that:

• The surgeon used a ballpoint pen, instead of using an FDA-approved skin marker, to initial the incision site on the correct side of the patient.

• MRI pictures relevant to the procedure were not displayed in the operating room before surgery began.

The hospital was fined $6,000 by the New York Health Department. They also had to perform the surgery again (not clear if they were paid twice for the surgery).

As part of the settlement, the hospital - St. Joseph’s Hospital Health Center in Syracuse, NY, agreed to take corrective action to prevent surgical mistakes.

My question is … Why didn’t they do this a decade ago?

Reading current stories like this one makes me shake my head in disbelief. Why isn’t the whole healthcare industry far beyond this point in advanced methods to assure error free human performance that are used in high reliability industries (for example, aviation and nuclear). Why aren’t more hospitals attending the TapRooT® Summit to learn best practices from other high reliability industries?

It seems that investing in malpractice insurance is the first approach to reducing risk rather than eliminating the real root causes of the lawsuits that result after one of these needless sentinel events.

If your hospital is ready to start effective learning from sentinel events, then it is time to go beyond basic root cause analysis tools and learn advanced root cause analysis at a TapRooT® Root Cause Analysis Course. For more information, see:

http://www.taproot.com/courses.php

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These are taken from real resumes and cover letters and were printed in Fortune Magazine:

1. I demand a salary commiserate with my extensive experience.

2. I have lurnt Word Perfect 6.0 computor and spreadsheet progroms.

3. Received a plague for Salesperson of the Year.

4. Reason for leaving last job: maturity leave.

5. Wholly responsible for two (2) failed financial institutions.

6. Its best for employers that I not work with people.

7. Lets meet, so you can ooh and aah over my experience.

8. You will want me to be Head Honcho in no time.

9. Am a perfectionist and rarely if if ever forget details.

10. I was working for my mom until she decided to move.

11. Failed bar exam with relatively high grades.

12. Marital status: single. Unmarried. Unengaged. Uninvolved. No Commitments.

13. I have an excellent track record, although I am not a horse.

14. I am loyal to my employer at all costs… Please feel free to respond to my resume on my office voice mail.

15. I have become completely paranoid, trusting completely no one and absolutely nothing.

16. My goal is to be a meteorologist. But since I possess no training in meterology, I suppose I should try stock brokerage.

17. I procrastinate, especially when the task is unpleasant.

18. As indicted, I have over five years of analyzing investments.

19. Personal interests: donating blood. Fourteen gallons so far.

20. Instrumental in ruining entire operation for a Midwest chain store.

21. Note: Please don’t miscontrue my 14 jobs as job-hopping. I have never quit a job.

22. Marital status: often. Children: various.

23. Reason for leaving last job: They insisted that all employees get to work by 8:45 a.m. every morning. Could not work under those conditions.

24. The company made me a scapegoat, just like my three previous employers.

25. Finished eighth in my class of ten.

26. References: None. I’ve left a path of destruction behind me.

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This excerpt should get you interested:

“The city was held responsible for the accident because there was a breach of protocol in the wheelhouse of the ferry: two captains are supposed to be present at all times and at the time of the accident only one was. Two men being held responsible for the accident are serving prison time after pleading guilty to negligent manslaughter.”

See:

http://ny-law-firm.com/new-york-law-blog/accidents/102/staten-island-ferry-accident

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WASHINGTON, Sept. 18 Teamsters-Metrolink

WASHINGTON, Sept. 18 /PRNewswire-USNewswire/ — The following statement is from Ed Rodzwicz, the president of the Teamsters Rail Conference and National President of the Brotherhood of Locomotive Engineers and Trainmen (BLET) about the Metrolink railroad accident in Chatsworth, California:

“A rush to judgment is never beneficial in a situation such as this. We are actively working with the National Transportation Safety Board to determine the causes of the tragic accident which occurred last Friday on the Metrolink line in Chatsworth, California. All of our members know that railroad jobs are inherently dangerous jobs, but an accident such as this can be avoided.”

“This accident would not have occurred had the Metrolink system been using positive train control technology. This safety system is designed to keep trains from colliding by preventing them from inadvertently passing a stop signal.”

“We have long supported the development and implementation of positive train control technology, and we urge the railroad industry and the federal government to redouble their efforts to eliminate the risks that positive train control technology is designed to address.”

“Our thoughts and prayers are with the families of those who perished or were injured as a result of this deadly accident. The Metrolink engineer operating the train was a dedicated union member and our thoughts also are with his family and friends at this time.”

The BLET represents over 38,000 men and women as locomotive engineers and trainmen working on freight, passenger and commuter rail lines across the United States. The BLET and the 32,000 members of the Brotherhood of Maintenance of Way Employes Division constitute the more than 70,000-member Teamsters Rail Conference.

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Rapetti Rigging Services Inc., the crane’s erector; Reliance Construction Group, the project’s general contractor; and Joy Contractors Inc., the project’s concrete and superstructure contractor, are $313,500 poorer after an OSHA fine related to a crane collapse in New York City. For details, see the OSHA press release at:

http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=NEWS_RELEASES&p_id=16601

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The following message is from the U.S. Chemical Safety Board, Washington DC

CSB Finds Static Spark Set Off Fire and Explosions at Barton Solvents Des Moines Facility, Investigation Finds Equipment Not Intended for Flammable Service or Properly Bonded and Grounded

Washington, DC, September 18, 2008 - A fire and series of explosions at the Barton Solvents Des Moines, Iowa, chemical distribution facility on October 29, 2007, was caused by a static electrical spark resulting from inadequate electrical bonding and grounding during the filling of a portable steel tank, the U.S. Chemical Safety Board (CSB) determined in a final report today.

One employee received minor injuries and one firefighter was treated for a heat-related illness in the accident, which occurred about 1 p.m. A large plume of smoke and rocketing barrels and debris triggered an evacuation of the businesses surrounding the facility.  As the CSB Case Study notes, the main warehouse structure was destroyed and Barton’s business was significantly interrupted.  The accident occurred about three months after a July 17, 2007, explosion and fire destroyed a Barton Solvents facility in Wichita, Kansas. The CSB attributed that accident to static sparks and lack of bonding and grounding as well in a June 2008 final report. 
CSB Chairman and CEO John Bresland said, ‘These accidents show the need for companies to address the hazards associated with static electricity and flammable liquid transfer.  They should apply good practice guidelines - outlined in our Case Study - to determine if facilities are properly designed and safety operated.’

The accident in Des Moines occurred in the packaging area of the facility as an operator was filling the 300-gallon steel tank, known as a tote, with ethyl acetate, a flammable solvent.  The operator had secured the fill nozzle with a steel weight and had just walked across the room when he heard a ‘popping’ sound and turned to see the tote engulfed in flames. Employees tried unsuccessfully to extinguish the fire with a handheld fire extinguisher before evacuating. 

CSB Lead Investigator Randy McClure said, ‘The CSB investigation found the nozzle and hose were not intended for use in transferring flammable liquids.  Furthermore, we found the steel parts of the plastic fill nozzle and hose assembly were not bonded and grounded.  Static electricity likely accumulated on these parts and sparked to the stainless steel tote body, igniting the vapor that accumulated around the opening of the tote during filling.’ 

The report notes that static electricity is generated as liquid flows through pipes, valves, and filters during transfer operations.  Metal parts and equipment must be electrically wired to each other, known as bonding, and then electrically connected to the earth, known as grounding. 

‘In this case, all the conductive metal objects in the nozzle and hose, and the steel weight which was suspended from the handle by a wire, were all isolated from ground and were susceptible to static accumulation and discharge,’ Mr. McClure said.  ‘This is a set-up for disaster.’

The packaging area - where the fire started - had no automatic sprinkler system and was adjoined to the flammable storage warehouse.  The investigation found the wall separating the two areas was not fire-rated. As a result, the warehouse was rapidly consumed, and although this area had an automatic sprinkler system, it was incapable of extinguishing the large blaze. 

The Case Study lists several key lessons for safe handling and storage of flammables.  ‘We would hope every operator of similar liquid transfer facilities downloads and studies this report and the earlier Barton Solvents Wichita report to avoid a repetition of these accidents,’ Chairman Bresland said.

Facilities are urged to ensure that equipment used to transfer liquids is properly bonded and grounded; fire suppression systems should be installed in packaging areas; and packaging to be used for flammable liquids - such as the portable steel tanks - should be separated from bulk storage areas by fire-rated walls and doors.

The CSB investigation determined that if Barton had implemented a comprehensive static electricity and flammable liquid safety program, in compliance with current regulatory standards and good practice guidelines, the fire likely would have been prevented.  These include OSHA’s Flammable and Combustible Liquids standard and codes and recommended practices of the National Fire Protection Association.

For more information, contact Public Affairs Specialist Hillary Cohen at (202) 261-3601 / 202-446-8094 cell. 

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Even where reporting of hospital mistakes (sentinel events) is required, some people point to actual mistakes that were NOT reported. This suggests that mistakes are under-reported.

The Philadelphia Inquirer wrote this article about the problem:

http://www.philly.com/inquirer/home_top_stories/20080912_Hospitals__mistakes_are_going_unreported.html

How bad is it? The Inquirer reports:

“In New Jersey, five of the state’s 80 hospitals failed to report a single preventable mistake last year, officials said. In Pennsylvania, some facilities didn’t report any serious events or even the near misses that might have harmed patients.”

And both Pennsylvania and New Jersey REQUIRE (by law) that many types of sentinel events be reported. Perhaps these hospitals are so good that they never make mistakes?

I believe that in addition to performing a root cause analysis on the causes of the sentinel events that they failed to report, the hospitals should also perform a root cause analysis on the reasons that the sentinel events were not reported in the first place. My guess is that the hospital administrators aren’t enforcing the SPAC (Standards, Policies, and Administrative Controls) for reporting sentinel events.

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A good article about the wrong approach to take when addressing a medical error. If the authors knew about TapRooT® root cause analysis techniques, they would be one step closer to an even better systematic investigative response to a medical error.

See the article at:

http://www.emsresponder.com/publication/article.jsp?pubId=1&id=8235

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See:

http://www.scotrecruit.com/cgi-bin/vacdetails.pl?selection=929821972&src=rss_jbe

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See:

http://www.bayt.com/job/job?xid=1065594

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What a mess. I-95 covered with Nickels!

Here’s a link to the local reporting:

http://www.local6.com/news/17493097/detail.html?rss=orlpn&psp=news

Here’s the local reporting (WMV format):

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Sounds like you need some Equifactor® Training before you apply for this job.

See:

http://www.lowonganpekerjaan.org/lead-reliability-engineer-fircroft.html

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Sanjay Gandhi, one of of TapRooT® Instructors, sent these photos of a recent 2-Day TapRooT® Incident Investigation and Root Cause Analysis Class held by ExxonMobil in Qatar.

If you need to schedule TapRooT® Training at your facility anywhere around the world, drop us a note at:

http://www.taproot.com/contact.php

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See:

http://www.chron.com/disp/story.mpl/business/6003738.html

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It seems that “human error” may be a “cause” of the deadly train crash is California. We can all look at cell phone policies, human alertness/situational awareness, signal effectiveness, etc., and try to implement corrective actions to improve human performance. But a better question might be:

” Why is a single human action safeguard the only thing between life and death of hundreds of passengers?”

That is the question behind an article published by the Associated Press that pushes for advanced technology to automatically stop these kinds of accidents. The cost - about $2 Billion for nationwide implementation.

This is a real case where a cost benefit /Return on Investment calculation would be interesting. My guess is that with train accidents all over the country, it would be worthwhile - but this is only a guess without someone actually running the numbers.

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Reported in a recent AP article: “The Metrolink spokeswoman who announced that a deadly train crash was caused by an engineer’s mistake resigned Monday because the railroad’s board had called her words “premature,” even though they were later backed up by investigators.” Using TapRooT® our investigators know that that this finding would only be a problem (Causal Factor) and not the root causes.

Denise Tyrrell made a swift announcement blaming the engineer driving the Metrolink train for failing to stop at a red light and causing the head-on crash while the National Transportation Safety Board members cautioned that they had not completed their investigation (AP Article).

Another report stated “Metrolink Engineer Texting With Teen moments Before Killer Commuter Crash”.

What comes to mind with these numerous responses is the role of company media relations and their role in high profile incidents. There appear to be two main actions that must be announced during such major incidents: interim correction actions in place to protect the public and disassociation of the incident to how the company actually runs.

With wreckage and recovery efforts in process and before the investigation has had a chance to really find out the problems and what the causes were, how does it benefit a company to assign human error immediately? Instead of finding the root causes to prevent or mitigate this type of incident from occurring, the parties involved got into a battle of who was right first. The investigation to the true root causes of the Metrolink incident has only just begun.

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Read the story HERE about Chicago Cubs catcher Koyie Hill almost losing the fingers on his right hand.

Then see this video (WMV format) …

Would it be a worthwhile investment?

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From the Houston Chronicle:

Valero, the nation’s largest refiner, sent inspection crews to refineries in Texas City, Houston and Port Arthur. Day said late Saturday that they found no significant damage to production units, but the plants don’t have electrical power. Day said crews are working with power providers.

Valero’s refineries also are developing startup plans, but Day said they had no timetable for when startup will begin or how long those processes will take.

Exxon Mobil and other refiners also were assessing damage.

In a briefing in Washington, U.S. Homeland Security Secretary Michael Chertoff said he expects it will take another day to determine Ike’s full impact on refineries, but a report from Shell’s massive Deer Park refinery and chemical complex at the Houston Ship Channel suggested damage could turn out to be less than feared.

The U.S. Energy Department said Saturday that Ike prompted shutdowns of 14 refineries in Port Arthur, Houston, Texas City and Corpus Christi.

Those plants process a combined 3.8 million barrels a day, or 22 percent of the nation’s daily refining capacity. They include Exxon Mobil’s Baytown refinery, the nation’s largest, and BP’s Texas City plant, the second-largest.

Other Gulf Coast refineries were operating, though some at reduced levels.

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The Associated Press says that oil field deaths are “soaring.”
But what do the statistics really show?

According to the article, “deaths per year” rose from 72 in 2002 to 125 in 2006.

But is total deaths the right statistic to measure? Or should it be deaths per 200,000 worker-hours?

If you look at those stats, the death rate increased in the early 2000’s, but has dropped since then.

The article claims that lack of training, drug use, and a high-pressure environment - as well as more drilling - are the cause of the increased accidents.

The article seems to find causes without root cause analysis or adequate evaluation of the statistics.

One thing I’m sure of is that the TapRooT® Users in the oil patch are working hard to maintain excellent safety records - even with increased drilling activity and a “high-pressure environment.” The discussions at the 2008 TapRooT® Summit about sharing safety best practices and how to have a good safety culture will help them improve.

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See the list at:

http://www.hss.energy.gov/CSA/bulletins.html

Topics include:

• Counterfeit Square D Circuit Breakers
• Silica Dust Exposure
• Automated External Defibrillators
• Avoiding Unwanted Chemical Reactions
• Use of Tungsten Welding Rods Containing Thorium
• SLead Safety Awareness
• Hexavalent Chromium Update
• Compressed-Gas Cylinder Safety
• Preventing Eye Injuries
• Control and Release of Property: A Guide to Good Practices for the Control and Release of Property
• Gas Buildup in Drums
• Natural Gas Line Breaks
• Hazards of Nitrogen Asphyxiation in Confined Spaces
• Boiler Safety Valve Test Failures
• Potentially Defective Battery Chargers (UPDATE)
• Respiratory Protection Incidents
• Working Safely with Acids
• Significant Radioactive Leak at Sellafield Due to Operational Complacency
• Vertical-Rail Fall Protection
• Vigilance in New or Infrequent High-Hazard Operations
• Safe Management of Mercury (Hg)

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The new Eclipse 500 very light jet has had its certification process upheld by an independent committee. However, the review panel said that the FAA and Eclipse aviation:

“…should conduct a root cause analysis” of trim, trim actuator and fire extinguisher problems reported by operators.”

For more info, see:

http://www.avweb.com/avwebflash/news/EclipseCertificationUpheld_198780-1.html

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For more information, see these links:

http://news.yahoo.com/s/ap/train_collision

http://www.pbase.com/espeeboy/scaxcpcurrier

Video from crash scene:

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See:

http://www3.thestar.com/static/googlemaps/starmaps.html?xml=080905_workplacedeaths.xml

There you will find an interactive map of the workplace accidents in Ontario. Just click on the pushpins of the map (at the link) and get a brief report of each accident.

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From posting:

Winnipeg Regional Health Authority / WRHA (Winnipeg MB): “Reporting to the Regional Manager, Work Order Management within Manitoba eHealth, the incumbent is responsible for facilitating problem identification, root cause analysis, communication..

See:

http://www.eluta.ca/search?ptitle=Service+Management+Analyst&position=fb26bb6a34efabda36634a6bf270ed40&imo=1

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See:

http://ap.google.com/article/ALeqM5h1LW28MLSIvWbUn_-nZbyXEuPmAwD935CQAG1

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